Predictive Value of Serum Uric Acid/Serum Creatinine Ratio on Cardiovascular and All-Cause Mortality in Patients with Normal Renal Function: an Analysis from the Real Clinical Practice in Italy

BACKGROUNDSerum uric acid (SUA) has been associated with cardiovascular (CV) and all-cause mortality; however, its interpretation is influenced by renal function. The serum uric acid to creatinine ratio (SUA/sCr) has been proposed as a refined marker, integrating urate burden with renal excretory capacity. Evidence from real-world populations with preserved renal function remains limited. METHODSA retrospective observational analysis was performed using administrative and laboratory databases from nine Italian healthcare entities, covering more than 7.6 million individuals. Eligible subjects were 18-95 years old, with estimated glomerular filtration rate (eGFR) [≥]60 mL/min/1.73 m{superscript 2}, serum creatinine (sCr) [≤]1.8 mg/dL, and no prior urate-lowering therapy. The index date was defined as the first SUA measurement between January 2017 and March 2022. A total of 739,950 participants were stratified into quintiles of SUA/sCr ratio. Outcomes were two-year all-cause mortality and CV events, including ischemic heart disease, heart failure, cerebrovascular disease, and coronary revascularization. RESULTSAll-cause mortality exhibited a U-shaped distribution, with the lowest risk in mid-quintiles and the highest in extreme quintiles (6.2% in quintile 1, 7.0% in quintile 5). Cardiovascular events showed a progressive increase, from 9.9% in quintile 1 to 11.6% in quintile 5. Sex-stratified analyses indicated higher absolute risks in men, whereas women demonstrated steeper relative increases across higher quintiles. In individuals with hyperuricemia, mortality and CV events rose consistently with increasing SUA/sCr values. CONCLUSIONSThe SUA/sCr ratio is an independent predictor of short-term mortality and cardiovascular events in individuals with preserved renal function. Its incorporation into routine risk stratification may support earlier identification of high-risk patients, particularly those with elevated SUA. CLINICAL PERSPECTIVEO_ST_ABSWhat Is New?C_ST_ABSIn this large, real-world study of nearly 740,000 adults with preserved renal function, the serum uric acid to serum creatinine (SUA/sCr) ratio emerged as a strong, independent predictor of two-year all-cause and cardiovascular mortality. The prognostic value of SUA/sCr was particularly evident in patients with hyperuricemia, where higher quintiles were associated with progressively increased risk of death and cardiovascular events. What Are the Clinical Implications?The SUA/sCr ratio, based on two inexpensive and widely available laboratory parameters, provides a practical tool for early cardiovascular risk stratification in patients without overt kidney disease.